Barron John O, Moon Soon, Tasnim Sadia, Toth Andrew, Sudarshan Monisha, Baker Mark, Murthy Sudish C, Blackstone Eugene H, Raja Siva
Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland, USA.
Department of General Surgery, South Pointe Hospital, Cleveland, USA.
Surg Endosc. 2023 Nov;37(11):8728-8734. doi: 10.1007/s00464-023-10263-y. Epub 2023 Aug 10.
Esophageal morphology in achalasia is thought to affect outcomes, with "end-stage" sigmoidal morphology faring poorly; however, evaluation of morphology's role in outcomes has been limited by lack of objective characterization. Hence, the goals of this study were twofold: characterize the variability of timed barium esophagram (TBE) interpretation and evaluate an objective classification of TBE tortuosity: length-to-height ratio (LHR). We hypothesized that the esophagus must elongate to become sigmoidal such that sigmoidal morphology would demonstrate a larger LHR.
Ninety pre-operative TBEs were selected from an institutional database. Esophageal morphology was categorized as straight, intermediate, or sigmoidal. Esophageal length was measured by a mid-lumen line from the aortic knob to the esophagogastric junction on TBE; height was measured vertically from the aortic knob to the level of the esophagogastric junction. The length divided by the height generated the LHR. Descriptive statistics and frequency of expert agreement were calculated. Median LHR was compared between consensus morphologies. A receiver operating characteristic (ROC) determined the optimal LHR for sigmoidal vs non-sigmoidal characterization.
From a total of 90 pre-operative TBEs, expert consensus morphology was reached in 56 (62.2%) cases. Pairs of experts agreed on morphology in 62-74% of TBEs, with all three experts agreeing on 46.7-48.9% of cases. Median LHR between expert consensus morphologies was 1.03, 1.09, and 1.24 for straight, intermediate, and sigmoidal morphologies, respectively (p < 0.001). ROC demonstrated that an LHR cutoff of 1.13 was 100% sensitive and 95% specific (AUC 0.99) for ruling out sigmoidal morphology.
These findings confirm our anecdotal experience that subjective morphology interpretation is variable, even between experts at a high-volume center. LHR provides an objective method for classification, allowing us to overcome the limitations of inter-observer variability, thus paving the way for future study of the role of morphology in achalasia outcomes.
贲门失弛缓症的食管形态被认为会影响治疗结果，“终末期”乙状结肠形态的预后较差；然而，由于缺乏客观的特征描述，形态学在治疗结果中的作用评估受到限制。因此，本研究的目标有两个：描述定时钡餐食管造影（TBE）解读的变异性，并评估TBE迂曲度的客观分类：长宽比（LHR）。我们假设食管必须延长才能变成乙状结肠形态，因此乙状结肠形态的LHR会更大。
从机构数据库中选择90例术前TBE。食管形态分为直形、中间形或乙状结肠形。食管长度通过TBE上从主动脉弓到食管胃交界处的中腔线测量；高度从主动脉弓垂直测量到食管胃交界处的水平。长度除以高度得出LHR。计算描述性统计数据和专家共识的频率。比较共识形态之间的LHR中位数。采用受试者工作特征（ROC）曲线确定区分乙状结肠形与非乙状结肠形的最佳LHR。
在总共90例术前TBE中，56例（62.2%）达成了专家共识形态。两位专家在62%-74%的TBE中对形态达成一致，三位专家在46.7%-48.9%的病例中达成一致。专家共识形态之间的LHR中位数，直形、中间形和乙状结肠形分别为1.03、1.09和1.24（p<0.001）。ROC曲线显示，LHR临界值为1.13时，排除乙状结肠形态的敏感性为100%，特异性为95%（AUC 0.99）。
这些发现证实了我们的经验，即主观的形态学解读存在变异性，即使在高容量中心的专家之间也是如此。LHR提供了一种客观的分类方法，使我们能够克服观察者间变异性的局限性，从而为未来研究形态学在贲门失弛缓症治疗结果中的作用铺平道路。
